Which of the following best describes the action of a nurse who documents her nursing diagnosis

Q: What is nursing diagnosis in nursing process?

The nursing diagnosis is the nurses clinical judgment about the clients response to actual or potential health conditions or needs.

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What is the best description of a nursing diagnosis?
Which of the following best describe the nursing process quizlet?
What is nursing diagnosis in nursing process?
Which of the following is most representative of the nursing diagnosis phase of the nursing process?

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Question	Answer
Which part of the nursing process includes the statement of the client's actual or potential problems?	nursing diagnosis
Which of the following is a characteristic of the nursing process?	The client is the central focus of the process
Implementation of the nursing process involves	giving actual nursing care
Which skill does the nurse use to determine the meaning of multiple cues when assessing clients?	critical thinking
The primary reason for nurses to use nursing care plans is to:	ensure consistency of care among all nursing staff
Which of the following is an example of objective data?	client's respirations are 14/minute
Which of the following is an example subjective data?	client complains of chest pain
Which of the following is an example of a client's chief complaint?	"I'm in the hospital for hip surgery."
A client is admitted to the hospital with complaints of chest pain during exercise. Which of the following questions would be a priority for the nurse to ask?	"What, if anything, helps to relieve your chest pain?"
After the nurse completes the nursing history and physical examination, which action is most appropriate?	data analysis
In this nursing diagnosis, "Hyperthermia related to exposure to hot environment as evidenced by temperature 101 Farenheit, skin flushed and warm to touch," which part represents the problem?	Hyperthermia
In the nursing diagnosis, "Chronic pain related to chronic physical disability as evidenced by patient's statement of pain as usually a 6 out of 10 on the pain scale, restlessness, facial grimacing with movement," which part represents the etiology?	chronic physical disability
Which of the following is a correctly written goal?	client will demonstrate sterile dressing technique by tomorrow (date)
Which of the following nursing diagnostic categories has the highest priority?	Ineffective airway clearance
When writing nursing care plans, the nurse should develop a plan for the client that is:	individualized
Which of the following is an independent bursing action?	Providing a backrub for a cliet
Which of the following is a dependent nursing action?	Abministering a routine medication
Which type of skill is the nurse using when inserting a nasogastric tube?	Technical
Which of the following best describes the use of evaluation in the nursing process?	The nurse rewrites the nursing care plan because the client is unable to meet the goal of walking in the hallway for 50 feet twice a day.
Choose all of the following statements that are correct regarding discharge planning.	Discharge planning should begin during the initial nursing interview and assessment. Discharge planning needs to be documented in the client's record.
Which of the folling is a priority nursing intervention?	Assisting the client to a full-Fowler's position because the client is having difficulty breathing in a supine position.
The nurse has recorded nursing care in the wrong client's chart. What action should the nurse take?	Cross out the error which a single line and write "error" and his or her initials.
Which of the following is a correct entry that can be made into a client's chart?	Client's dressing is dry and intact.
Which of the following is a correct method for documenting subjective data?	Client states, "I feel nauseated."
On which form would the nurse document vital signs?	Flow sheet
On which form would the nurse document what a wound looked like during a dressing change procedure?	Progress note
A client complains of feeling bloated after surgery. Physical examination reveals the abdomen is filled with gas. The nurse would document the findings as:	Distended abdomen
The _________ is a method by which to provide individualized care.	nursing process
The primary goal of nursing is to help individuals meet their _______.	basic and higher-level needs
The nursing process helps the nurse provide care in a structured, purposeful, and ________	effective way
Trial and error is an ______ approach to problem-solving	experimental
Scientists and healthcare researchers use a _____ method to investigate problems and to arrive at solutions	precise
Nursing process is an important method for providing _______ and observable evidence	measurable
_______ thinking is an important nursing strategy for problem-solving.	critical
A form of trial-and-error experimentation is used in _______ studies when testing several solutions to a problem.	laboratory
A client who lacks a sense of smell often is	anorexic
_______ data consist of the client's opinions or feelings about what is happening	subjective
The nurse can draw conclusions about the client's health problems though systematic _______.	data analysis
Nursing ________ is the systematic and continuous collection and analysis of information about a client's health status.	assessment
_______ is an assessment tool that relies on the use of the five senses	observation
_______ observation is involved in the assessment of muscle strength, temperature, moisture, edema, rash, or swelling	tactile
The problem of a client is a ______ problem if it needs health treatment	clinical
The ______ part of the diagnostic statement is the cause of the cause of the problem	etiology
The ________statement connects problem, etiology, and signs and symptoms.	diagnostic
_________ is the identification of nursing interventions to develop and achieve goals to prevent, reduce, and eliminate problems	planning
A _________ provides a basis for prognosis and medical treatment decisions	medical diagnosis
______ of a nursing care plan may also be referred to as providing nursing interventions	implementation
administering medication is a _______ action	independent
_______ skills involve knowing and understanding essential information	intellectual
is the basic skill of identifying a problem and taking steps to resolve it	problem solving
is an experimental approach that tests ideas to decide which methods work and which do not	trial and error problem solving
allows researchers to discover the best possible safe and effective treatments for disease or dysfunction	scientific problem solving
a complicated mix of inquiry, knowledge, intuition, logic, experience, and common sense.	critical thinking
as a nurse, you combine critical thinking skills with scientific problem solving method to identify client problems and to provide care in a structured, purposeful, and effective way	nursing process
use the nursing process to develop guidelines when caring for a client. These guidelines are the :	Nursing Care Plans (NCP)
the systematic and continuous collection of data	nursing assessment
the statement of the client's actual or potential problem	nursing diagnosis
the development of goals for care and possible activities to meet them	Planning
the giving of actual nursing care	implementation
the measurement of the effectiveness of nursing care	evaluation
the needs of the client are identified, not the needs of the nurse, family, or other healthcare providers	client-oriented
goals, objectives, or expected outcomes are established as an early part of the nursing process	goal-oriented
are measurable outcomes that can be achieved in hours, days, or weeks, depending on the individual problem	short-term goals
take the short-term goals into consideration but also provide guidance for the days, weeks, or months during and after the time a client is seen by a health provider	long-term goals
existing needs often are the priority over ______. which are often listed as 'at risk for'.	potential needs
include all the measurable and observable pieces of information about the client and his or her overall state of health	objective data
consist of the client's opinions or feelings about what is happening.	subjective data
an assessment tool that relies on the use of the five senses (sight, touch, hearing, smell, and taste) to discover information about the client.	observation
a way of soliciting information from the client	health interview or nursing history
the nursing progress notes are commonly referred to as the :	nurses' notes
Through systematic ______, you can draw conclusions about the client's health problems. You also use critical thinking skills to ponder other questions that might be important.	data analysis
a statement about the actual or potential health concerns of the client that can be managed through independent nursing interventions.They are clear, concise, client-centered, and client-specific statements	nursing diagnosis
means that you will work together with the physician or other healthcare providers	collaborative problem
the development of goals to prevent, reduce, or eliminate problems and to identify nursing interventions that will assist clients in meeting these goals.	planning
a measurable client behavior that indicates whether the person has achieved the expected benefit of nursing care. it may also be called a goal or objective	expected outcome
an expected outcome or goal that a client can reasonably meet in a matter of hours or a few days	short-term objective
an outcome that the client ultimately hopes to achieve but that requires a longer period of time to accomplish	long-term objective
also called 'nursing orders or nursing actions', are activities that will most likely produce the desired outcomes.	nursing interventions
the entire nursing team usually formulates the nursing care plan at a meeting called a:	nursing care conference or team conference
a flip-file with card slots or a notebook for each client being treated by a unit or nursing care team. Contains records of backround information and care related to the client's medical treatment	Kardex
_____ of a nursing care may also be referred to as providing nursing interventions	implementations
actions that carry out a physician's orders regarding medication or treatments are ______ that you must follow explicitly.	dependent actions
are those that you perform collaboratively with other care providers; the physician may write orders for some of these actions.	interdependent actions
are nursing actions that do not require a physician's order.	independent actions
an important aspect of legal requirements of nursing practice	accountability
involve knowing and understanding essential information before caring for clients	intellectual skills
involve believing, behaving, and relating to others.	interpersonal skills
such as changing a sterile dressing or administering an injection, require safe and competent performance	technical skills
measuring the effectiveness of assessing, diagnosing, planning, and implementing. analyzing the client's responses, identifying factors contributing to success or failure, and planning for future care.	evaluation
the process by which the client is prepared for continued care outside the healthcare facility or for independent living at home	discharge planning
a manual or electronic (computer) account of a client's relationship with a healthcare facility.	health record
the health record is ______ that the healthcare agency and providers have acted responsibility and effectively.	documented evidence
MIS	medical information system
a collection of various forms and documents	manual health record
essentially summarizes the progress of the client toward achieving his or her care plan goals.	progress notes.
a type of nurses' notes that essentially documents what is occurring throughout the day in a chronological manner	narrative charting
When _____ charting is used, the whole healthcare team works collaboratively to identify priority problems, and they work collectively to solve these problems. also called focus charting	problem-oriented medical records (POMR)
a type of narrative charting that usually uses a flow sheet listing body systems and their typical findings, such as lung sounds: clear, rales, or rhochi.	Charting by exception (CBE)
which the emphasis is on quality care that is delivered in the most cost-effective manner. also known as case studies, care mapping, collaborative pathways, or critical pathways.	case management
lists all medications that the physician has ordered for the client, with spaces for the caregiver to mark when medications are given.	medication administration record (MAR)
a means of exchanging information between the outgoing and incoming staff on each shift	change-of-shift reporting
caregivers move from client to client, discussing pertinent information.	walking rounds
erasures and the use of correction fluid on the client's health record are :	illegal

What is the best description of a nursing diagnosis?

According to NANDA-I, the official definition of the nursing diagnosis is: “Nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes.

Which of the following best describe the nursing process quizlet?

Which of the following definitions best describe the nursing process? A systematic problem solving approach that guides all nursing actions.

What is nursing diagnosis in nursing process?

The nursing diagnosis is the nurse's clinical judgment about the client's response to actual or potential health conditions or needs.

Which of the following is most representative of the nursing diagnosis phase of the nursing process?

Which of the following behaviors is most representative of the nursing diagnosis phase of the nursing process? 1. Identifying major problems or needs.

Which of the following best describes the action of a nurse who documents her nursing diagnosis

What is the best description of a nursing diagnosis?

Which of the following best describe the nursing process quizlet?

What is nursing diagnosis in nursing process?

Which of the following is most representative of the nursing diagnosis phase of the nursing process?

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